here it was again: During his first week in office, even as he unveiled policies affecting momentous issues from women’s health and war refugees to oil pipelines and immigration, President Trump seemed fixated on … less portentous topics.

He tweeted his scorn for the anti-Trump women’s marches in cities around the world the day after his inauguration. He told congressional leaders he lost the popular vote because more than 3 million people cast illegal ballots. After ABC’s David Muir, in an interview that aired Wednesday night, told the president, “I don’t want to compare [inauguration] crowd sizes again,” Trump plowed ahead, showing off a framed photo and saying, “the audience was the biggest ever, but this crowd was massive. Look how far back it goes. This crowd was massive.”

In early January, Trump had told “60 Minutes” that after he was sworn in he would be “very restrained” on Twitter, “if I use it at all.” That has not happened. The new president has continued to respond forcefully to seemingly every perceived slight. Is it deliberate? Or does his behavior reflect a personality trait such as narcissism, some kind of obsession that is driving compulsive behavior, or both?

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STAT interviewed 10 psychiatrists and psychologists — some supporters of Trump, some not — about the president’s behavior and what it might say about his personality and mental health. All are respected in their field and close observers of Trump. They based their views on his books, public statements, appearances, and tweets, but emphasized that they have no firsthand knowledge of Trump.

As a result, they can’t rule out that the president’s actions are part of an intentional political strategy, and not a reflection of particular mental states. After all, his confrontational style and egotism — adorning buildings around the globe with his name — served him well in business and brought him to the White House.

Still, even at arm’s-length, the analyses were strikingly consistent. Several of the experts, for instance, advanced the view that, as New York University psychologist John Montgomery put it, Trump shows “compulsive ‘more-than’ behavior,” meaning a desperate need to keep from feeling, even fleetingly, that he might not be superior to everyone else.

“I think it completely fits with him making up the millions of illegal votes idea … and not being able to accept the clear data about Obama’s [first] inauguration having a far bigger crowd,” said Montgomery, who voted for Hillary Clinton.

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Dr. Robert Pyles, a Massachusetts psychiatrist and Trump supporter, said the president’s behavior is within the normal range: “My liberal colleagues feel frightened and betrayed, so they go to this hysterical extreme of saying Trump has narcissistic tendencies, but what political leader doesn’t?”

Without exception, the mental health professionals said that would-be diagnosticians, including pundits and political foes, are misguided in asserting that Trump has a mental disorder — for one fundamental reason. According to decades-old criteria established by the American Psychiatric Association, a diagnosis of mental illness requires that someone’s behavior, emotions, or beliefs have two key attributes: They cause the individual to suffer clinically significant distress or impairment.

“Trump doesn’t meet DSM criteria” for any mental disorder, said Dr. Allen Frances, a professor emeritus of psychiatry at Duke University who oversaw the creation of a previous edition of the APA’s Diagnostic and Statistical Manual of Mental Disorders, considered the bible of psychiatry. “I wrote the criteria and should know how they are meant to be applied: Personality disorder requires the presence of clinically significant distress and/or impairment. The armchair, amateur diagnosticians seem either to be unaware of this requirement, or carelessly choose to ignore it.”

The APA’s “Goldwater Rule” prohibits psychiatrists from making public comments on the mental health of anyone they have not treated, but some psychiatrists believe that the rule restricts their right of free speech and argue that it is acceptable to discuss a public figure’s behavior with the appropriate caveats.

In an interview Wednesday with ABC News, President Trump discusses the size of the crowd at his inauguration.ABC News via YouTube

The threat of ‘less than’

While Trump does not meet psychiatry’s criteria, many of the experts said his public behavior offers a window into his emotional makeup and what drives him — the realm of psychology rather than psychiatry.

The experts see three key psychological traits: Trump’s apparent anger and his resulting confrontational behavior (and the related joy he seems to take in attacking those who challenge or criticize him), his narcissism, and his seemingly compulsive need to tweet.

Trump, said Ben Michaelis, a psychologist in private practice in New York City and not a Trump supporter, “has an intense focus on his popularity and the idea that somehow someone would be greater than him bothers him. It doesn’t take a mental health professional to figure that out.”

ABC’s Muir asked Trump about spending much of his Jan. 21 speech at the CIA’s memorial wall talking about the “crowd size at the inauguration, about the size of your rallies, about covers on Time magazine,” and wondered, “When does all of that matter just a little less … now that you’re the president?”

Trump didn’t answer directly. Instead, he described the speech as “a home run” that received “the biggest standing ovation since Peyton Manning had won the Super Bowl.”

That, too, fits the idea that Trump cannot abide feeling “less than,” in Montgomery’s words. Many critics took issue with the CIA speech, he noted, “so Trump makes up a completely absurd and counter-factual story about how great it was,” another “‘more than’ compensation for feelings of ‘less than.’”

“I see personality traits there that, if he came to me [for therapy], I wouldn’t be shocked.”

Dr. Janis Chester, Delaware psychiatrist

Psychiatrists who voted for Trump have also wondered about his behavior. “I see personality traits there that, if he came to me [for therapy], I wouldn’t be shocked,” said Dr. Janis Chester, a psychiatrist in Delaware. “But he couldn’t be what people say and have kids who are so wholesome and so connected to him even after his divorces” from their mothers.

Other mental health professionals see in Trump’s years of insults of beauty pageant contestants, political rivals, journalists, and many others evidence that he derives deep satisfaction from “abusing and hurting people,” Montgomery said.

Trump would hardly be unique on that score. Studies have shown that social aggression and, in particular, revenge, release neurochemicals that can trigger a sense of reward. Research has also found that people feel good when they engage in “altruistic punishment,” or vengeance against someone who has (in the eyes of a beholder) committed some infraction. But Montgomery suggested that Trump might feel that more than most: “If someone makes him feel bad, he seeks revenge on them.”

“Anger seems to be a very prevalent emotion for Trump,” said psychologist Dan McAdams of Northwestern University, who is not a Trump supporter. Although psychology generally considers anger a negative emotion and one that is unpleasant to feel, “for Trump it is also positive,” he said, “because it gives him a sense of righteousness.”

Inflated self-regard

Accounts of Trump’s childhood describe how he “wanted to be No. 1” and had a deep “need to excel.” While that describes countless people who go on to stellar achievements in business, politics, sports or other fields, McAdams sees something more extreme in Trump because it is combined with intense narcissism.

Every psychiatrist and psychologist who spoke to STAT mentioned what they perceive to be Trump’s inflated self-importance and self-regard, and a need for excessive admiration, for the attention and adulation of others, and to feel dominant and superior.

There are two views of where that narcissism comes from, McAdams said. Some psychologists trace it to not receiving enough attention as a child. “In this view, the child’s need to be the center of attention and the apple of someone’s eye wasn’t gratified,” McAdams said. “So they’re desperately trying to get that experience as an adult. This goes with seeming to have high self-esteem but really not having it, or why are they out there constantly seeking glory?”

A competing view, with stronger scientific evidence, is that a child who “gets reinforced like crazy for being the center of attention” becomes emotionally addicted to that adulation, McAdams said. Trump’s father, Fred, told Donald, according to biographies, “You’re my favorite, you’re a killer,” McAdams noted. “Rather than satisfying and soothing” one’s emotional and psychological need to be the focus of attention and valued, he said, “that pours gasoline on the fire,” stoking blazing narcissism and the need to “seek glorification over and over because they can’t get enough.”

Hence Trump’s post-election victory rallies and the apparent need to keep himself the center of attention through provocative tweets. “It’s affirmation that he needs,” said McAdams.

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Before politics, Trump’s apparent need to be front-and-center manifested itself in his practice of stamping his name on nearly everything he did in business, from buildings and a “university” to steaks and wine. Of course, that’s not necessarily evidence of narcissism; it could be smart marketing. But McAdams, who combed through Trump books and news accounts, points to an especially telling episode. At his father’s 1999 funeral, Trump’s remarks focused on himself — “It was the toughest day of his own life” — and on how Fred’s greatest achievement was raising the famous, brilliant, mega-successful Donald.

When narcissists do not receive the admiration, attention, love, and adulation they need, when they begin to feel that their greatness is not being recognized and paid obeisance, they typically feel either rage or an intolerable, jump-out-of-their-skin anxiety.

“The obvious thing with Trump is that he can’t tolerate psychological pain,” said psychologist Gary Greenberg, a therapist in Connecticut, author of the 2013 expose “The Book of Woe: The DSM and the Unmaking of Psychiatry,” and not a Trump supporter. “He has to immediately eject the pain; he can’t sit with it.” That is typical of a compulsion, he added, in which “you have to act on what you feel. You wake up at 3 a.m. and you have to say something” to drain the painful anxiety, including anxiety that comes from bottling up anger for even a moment.

Enter Twitter.

Donald Trump stands next to one of his three Sikorsky helicopters at New York Port Authority’s West 30th Street Heliport in 1988.Wilbur Funches/AP

Anxiety-driven compulsions

A compulsive behavior is not necessarily evidence of a disorder. Whether it’s checking one’s phone constantly, playing video games, shopping, or any other behavior that can be taken to extremes, “it’s a mental disorder only if it doesn’t provide a pleasurable reward or benefit” and if it does cause that requisite duo of distress or impairment, Duke’s Frances said.

But while Trump’s — and other prolific tweeters’ — embrace of 140-character communication is not compulsive in the clinical sense, it likely reflects a milder compulsion. A compulsion is an action that “is forced on a person” because it is the only way they can relieve unbearable anxiety, said Frances, who has been critical of Trump’s policies and actions.

https://twitter.com/realDonaldTrump/status/824968416486387713

In this understanding, the anxious person seizes on whatever behavior can defuse the anxiety — hence the constant hand-washing or picture-straightening of obsessive-compulsive disorder. Many people, but especially narcissists, feel anxious about being dissed or insulted or verbally attacked in public; most can only wish they had a platform to strike back. Trump does. At his first post-election press conference this month, Trump assailed what he called “fake news” stories about him and said that while many people are victimized by such stories, “I have this great megaphone, I can fight back.” And he has, such as when he tweeted about Meryl Streep after her anti-Trump speech at the Golden Globe Awards.

Chester, the Delaware psychiatrist, sees that as strategic, not evidence of psychological issues. Trump’s angry tweets used to bother her, she said, “but now I think it’s deliberate: He sets the news cycle. He knows how to use it to his benefit,” including by throwing raw meat to his core supporters.

“Publicly observed behaviors are important data but only a piece of the puzzle,” said psychiatrist Dr. Matthew Goldenberg, of Yale University, who is critical of Trump. “A person acting in a certain way — for example, overly aggrieved — may do so because they are legitimately aggrieved, which may seem reasonable or may be a reflection of underlying vulnerability to offense. But he or she may do so not as a reflection of true feelings but in order to achieve certain goals, such as sympathy or political advantage.”

Experts doubt that Trump will change: At age 70, he is likely set in his ways, and his behavior has brought him huge success. That’s a key reason why “people trying to diagnose Trump as having a mental disorder are wrong,” said Frances. From Trump’s late-night, angry tweets to his denying that he did or said something caught on video, “he apparently gets pleasure, not distress, from these things, and they made him president,” Frances said. The tweeting, in particular, “makes perfect sense, and he’s rewarded for it,” with attention and, from his fans, cheers.

Frances warned, however, that this is a potential pitfall of psychoanalysis from afar: No outsider can know whether Trump, alone with his thoughts and emotions at 3 a.m., is feeling significant enough distress to place him that much closer to meeting the criteria for a mental disorder.

What an outsider can tell, though, is that far from impairing him, these behaviors vaulted Trump into the highest office in the land. That criterion alone rules out mental illness. “He’s crazy like a fox,” said Frances.

The observation that DSM diagnoses only apply to “distressed” patients is not related to psychopathology. Alcoholism is a psychiatric disease, but alcoholics are not necessarily “distressed” as long as they can self-medicate. In the same way, patients with age-related dementia may be unaware that they have dementia–it’s the stinking caregivers who have the problem. The brainwashed jihadi turned suicide bomber is not “distressed”–he is on a heroic mission to win himself seventy-two virgins. The requirement of “distress” is significant mainly to the therapist who depends on patient motivation for treatment (and, incidentally, payment).
Trump is not distressed about himself, owing to the defense mechanism (grandiosity) characteristic of such personalities; and he is not distressing to his followers, whether they are simply lacking in insight, dependent personalities, or opportunists. His actions can nonetheless be extremely distressing to the people of these United States, unless the denizens of the “swamp” he was elected to drain take effective action.

This is so cool! Is this being done for fun? I wonder what their purpose is? To save us from what can be tyranny? Meh, donald trump is one funny dude anyways. But to let someone who has no sense of duty to the country, well idk. This is cool nonetheless…

The question i like to ask consistently, i may add, is whether donald trump is fit for president. Gis dumbedness seems to be a positive trait because everyone knows when he is doing something wrong. I find that unifying… Well not much more here to add. Oh and we as a people, as the world are more better than one person. It just seems that donald trump is reaching more than his current jurisdiction. I mean what does he think he is.. , God?

Now that there appears to be an FBI criminal investigation into trump campaign and Russian operatives, can anyone speak to what may happen when an angry, unhinged paranoid and narcissistic person is backed into a corner and has access to nuclear codes?

I am not a doctor. I am a citizen who wonders if Trump’s behaviors are interfering with his abilities to successfully lead the country in the early part of the 21st century. Actually, according to Hans Morgenthau’s book, “Politics Among Nations,” do we even need to know “why” he is doing these things? The point is to look at the strategy and philosophy behind the actions, what the actions are, and what they accomplish. It is the reality view. What is the philosophy behind calling up allies and endangering peaceful relationships with them? The accomplishment will be a world which is not as predictable and safe as if previously has been. What is the idea behind confronting an unstable country that possesses nuclear weapons and is looking for an excuse to fire them? The action sounds like children taunting each other, “I’m the boss.” “No, I’m the boss.” Whereas at least 30 years ago, the military has said its focus has to be in the cyber realm and less on a conventional weapons strategy. What about people who are hurting and dying and needing medical care? Especially your own voters? Why take that money and put it into conventional military hardware, which will accomplish much less than a cyber operation such as the cooperative operation between US-Israel that destroyed nuclear processors in Iranian nuclear cylinders? My point is that psychology and psychiatry are not the best tools to analyze the actions (potentially illegal and unethical) and outcomes of a powerful political figure? Where psychiatry and psychology come into play is when the actions appear to threaten the security of the country and the world. At that point, if it is determined that it is necessary to remove this individual from power, perhaps a psychiatric or psychological diagnosis could be one way of accomplishing that. But rational minds must get together and weigh the risks of keeping this person in power and figure out the best way to remove him from office if they deem him to be a security threat to the world.

I have always been fascinated by psychology and Trump fully has my attention. I truly feel his compulsion, response to criticism and the absolute fear of being inferior is beyond a reasonable doubt he has a mental disorder he is absolutely unable to control. Nobody likes to be wrong or not get their way and sometimes they do back themselves into a corner. However they throw in the towel because they can rationalize that gross persistence not only would label you inccorect momentarily but loose credibility indefinitely. There is a yuge difference between being wrong and unhappy about it vs refusal to admit. There is a side of my family who behaves the same, it is a miserable life for them and the people close to them. I’d love to say it is just a desperate attempt to cover up Russia but like my family members, he seems to lack the cognitivity to stop. Their cognitive impairment literally prevents them from understanding that arguing proven facts puts them in an even more negative light. It is astounding how their phobia of being inferior/wrong infact causes the very scenario they fear the most. Imo it’s severe mental illness. To put in perspective it’s the equivalent to someone who is terrified of the dark refusing to turn on the lights and smashes the bulb in rage when lit.

It is certainly true that the DSM-V requires a finding of personal distress or significant impairment in social or occupational functioning as a prerequisite to making a diagnosis of any clinical mental disorder, including personality disorder. But ……

It is entirely facetious for these psychologists and psychiatrists to hedge their statements this way, saying that they cannot be “sure” that Trump is mentally ill for lack of certainty that he would feel distressed by the perturbations of his personality: anyone who feels compelled to stay up at night, broadcasting viciously offensive tweets against a broad array of persons unknown to him and merely for the gratification of his own internal psyche is most obviously a “distressed” person.

One doesn’t need to see the hammer fall in the forest to know that it makes a sound when it does !

Trump is an OBVIOUSLY DISTRESSED PERSON.

Further, his “social and/or occupational functioning” is clearly impaired: He has been repeatedly divorced in life and has had manifestly distorted and disturbed interpersonal relations, whether with Melania, his children or any person who works in his inner circle. His pursuit of “grabbing pussy”, i.e., sexually assaulting women who come into his presence, is another “clearly impaired” element of his interpersonal functioning. His compulsive lying, again, another deeply disturbed such element. There are many others.

Trump is not merely another “sly fox”, a “calculating politician”. To minimize and apologize for his conduct in this manner would make Hitler and Mussolini into such “sly foxes”, right up to the point that they perished. One cannot be called “mentally ill”, unless and until one “loses”, eh??

The truth is that quite many people with severe personality disorders can be and are highly successful people, whether in terms of monetary or social success. Quite many garden-variety criminals (i.e., “psychopaths,” those having an “antisocial personality disorder”) are highly monetarily successful people and, many of these, very well regarded in their own circles, even idolized by the public (e.g., Al Capone and other celebrity criminals). The fact that they have not been caught or been sent to jail certainly does not detract from their diagnosis! Nor, too, does the fact that they do not collapse into tears and shudders at every moment of their lives prevent a competent psychiatrist from diagnosing their personality disorders!

Trump is quite obviously a psychopath: A deeply disturbed, personally and severely distressed man, who manifests a severely narcissistic personality without any moral compass, whatsoever. More than a merely Narcissistic Personality Disorder, he warrants the diagnosis of Antisocial Personality Disorder, because of the strong likelihood that he has repeatedly engaged in criminal acts – sexual assault, criminal fraud, perjury and, now, treasons of various kinds related to the Russian affair. His core belief is that, “I must do FOR me before anyone else does TO me.” This belief system — which abnegates the rights of others and the rule of law, in favor of satisfying his own immediate desires — is what characterizes the common criminal, i.e., the “antisocial personality”. Those psychiatrists who assert, to the contrary, that Trump is some mere and harmless narcissist, who slyly manipulates the press and the public into slavishly aggrandizing him, have been blinded by his celebrity: They would make lambs of Hitler and Mussolini. They aren’t worthy of the titles they themselves hold.

@FecklessFreddie: You are clearly no physician. I am. Your constant apologizing for Trump manifests a rather sick kind idolatry of him. You ignore the obvious in your effort to deny the reality of his illness. One has to wonder about your own.

Just as an example, here. You idolize Trump’s ability to “get things done”. But where in the last 6 weeks since being inaugurated has Trump actually succeeded as President in getting anything “done”. Certainly not in the area of immigration policy ! His Muslim Ban 1.0 was immediately struck down. His Muslim Ban 2.0 is well on its way to meeting the same fate. Will he then go for a Muslim Ban 3.0 ?

Some armchair psychiatrists would say that the definition of insanity lies in repeating the same action expecting a different result. How many times will Trump have to attempt to unconstitutionally exclude Muslims from the United States before you will agree that he’s insane ?

Oh, sorry, you will always deny that. But denial of reality is an element of mental illness ! Time for you to start reading the DSM-V.

Why do people constantly think that Trump has any kind of strategy, ideology, or even logic to what he does? He’s not “crazy like a fox” – he’s just crazy – but logical people simply cannot accept that there isn’t any underlying substance.

But when you examine Trump’s entire career – his tactics, his actions, his words, his interests, and the fact that he would be much wealthier if he had simply put his inheritance in an “indexed fund” than what he did (translation he has spent his entire career systematically LOSING money).

And when you add in the manner in which he LOST money by stiffing working people, banks, partners, etc., the conclusion is that he indeed is in some way defective – but people simply don’t want to risk saying so.

First, he isn’t worth $10 billion by anyone’s estimate but his own – and even Trump says is varies from day to day according to his mood.

Second – whatever the figure – he would have had MUCH MORE if he would have put his inheritance from his father in an “indexed fund” – which means everything he has done in his entire career has resulted in LESS MONEY than if he had done NOTHING at all.